Advice on medical billing. This information is intended to be used for informational purposes only and not intended to be used for medical diagnosis or treatment. This blog assumes no liability on advice or opinions given.

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Icd-9 is a diagnosis. The diagnosis is the reason a patient is being seen. For example: a patient comes to see the doctor for a headache. The diagnosis would be headache. A number is assigned to this by a coder. They choose the appropriated diagnosis code from the ICD-9 book and code it on the encounter form.

What is a CPT code?(Current Procedural Terminology)

Cpt code is the procedure that is being done. Ex. A new patient comes in to see the doctor for the headache, the doctor examined the patient. The cpt code would be a new office visit. The coder would then choose the appropriate cpt code from the CPT book and code it on the encounter form. Examples 99201-99205 are new office visit codes in the cpt book. Depending on how long the patient was seen determines the level and should be done by a certified coder or someone who has experience.

What is an encounter form?

You may have seen it before. This is the form the doctor attaches to your chart to give to the lady at front desk. This form has your demographic information along with insurance information. The office usually picks frequent icd-9 and cpt codes that they use often and preset it on the form. Most of the time the doctor will check off what diagnosis (icd-9) and procedure (cpt) they used and give to the person that will do the charge entry.

What is charge entry?

Charge entry is just entering the cpt codes and icd-9. The registration(the patients information, name, date of birth, social security number, address, insurance, etc) is usually already done by someone else who just does registration. When you are doing charge entry you enter information that is on the encounter form. Along with the patient demographics, you need to enter the date of service, the cpt code, the icd-9 and the charge amount if needed. Sometimes you need to put in the authorization number or referral information.

Other information that is needed to get the claim paid is normally preset to come out on all claims from the initial set up such as the provider tax id and address.